SPECIAL REPORT: SUBSTANCE USE
Special Report Chairperson: Tony P. George, MD, FRCPC
The majority of adults worldwide drink alcohol,1 and most individuals drink alcohol without developing problems related to alcohol use.2 Yet, epidemiological data in the United States suggest as many as 13.9% of individuals meet criteria for a current alcohol use disorder (AUD) and approximately one-third (29.1%) meet lifetime criteria.2 Globally, alcohol use contributes to 5% of the total disease burden and is associated with tremendous social and economic costs.1
AUD is defined by the DSM-5 as clinically significant impairment or distress, resulting from endorsing at least 2 of 11 symptoms in the past 12 months.3 The 11 symptoms are intended to fall into 4 symptom clusters (Table).
Table. The 4 Symptom Clusters
The DSM-5 also provides a definition of remission from AUD based on the length of time that symptoms are no longer present. Early remission is defined as greater than 3 months and less than 12 months of endorsing no symptoms of AUD, apart from craving. Sustained remission is defined as 12 months or more of endorsing no symptoms of AUD, apart from craving. Craving is excluded from definitions of remission, given that craving could persist long after remission of other AUD symptoms is achieved.4
Although AUD is often described as a chronic and relapsing condition, remission from AUD is achievable. In fact, most people with AUD enter remission even without treatment.5 This natural recovery process is the most common pathway to AUD resolution.5,6 As noted previously, it is important to highlight that many people drink alcohol without developing problems,2 and those who drink less have lower morbidity and mortality.7
Also In This Special Report
Recovery-Based Approaches and Forward-Thinking Policy: Implications for Addiction Care
Tony P. George, MD, FRCPC
Substance Misuse in College Students
Ashley E. Kivlichan; Darby J.E. Lowe, MSc; Tony P. George, MD, FRCPC
Cannabis Legalization: What Psychiatrists Need to Know
Samantha Johnstone, BA; Kevin P. Hill, MD, MHS; and Tony P. George, MD, FRCPC
Dual Diagnosis: Double the Stigma, Double the Trouble
Darby J.E. Lowe, MSc; Emily Simpkin, RN; Tony P. George, MD, FRCPC
As early as the 1700s, AUD recovery was defined by complete and total abstinence from alcohol use, and this view persisted until the 1900s.8 Although in some spaces, such as Alcoholics Anonymous, total abstinence is still considered a required aspect of recovery, current definitions have shifted toward a focus on the importance of overall functioning and general well-being with or without abstinence.8,9 Recovery from AUD includes broader domains of well-being, quality of life, social environment, and health functioning, with subdomains of cognitive and emotional functioning, purpose in life, engagement in valued activities, social network support, cultural connections, reductions in harmful use, and ecological and contextual features that support health (Figure).
Figure. Domains and Subdomains in Definitions of Recovery from AUD
The Substance Abuse and Mental Health Services Administration (SAMHSA) and the National Institute on Drug Abuse both define recovery as “a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.”10,11 SAMHSA noted the importance of abstinence as 1 example of achieving improvements in health.
In 2017, a meeting was convened by recovery researchers with a specific focus on examining the concept of recovery based on a literature review and ideas generated by group members.12 Their final definition was: “Recovery is an individualized, intentional, dynamic, and relational process involving sustained efforts to improve wellness.”12 This definition acknowledges the presence and importance of individual differences in the recovery process, focuses on the recovery process as being both intentional and dynamic, and is one that requires sustained efforts to improve wellness. Improving wellness includes not only the physical benefits associated with reducing alcohol use,13 but also benefits related to psychosocial and functional dimensions of wellness (eg, social, emotional, and financial).10
The shift away from abstinence-based definitions of recovery and toward nonabstinent definitions of recovery that consider quality of life and well-being is also supported by preliminary quantitative and qualitative research in this area. Witkiewitz and colleagues14 social functioning, employment followed individuals enrolled in AUD clinical trials for 3 years and identified 4 profiles of individuals based on intensity and frequency of alcohol consumption, as well as other indicators of health and well-being: (1) low-functioning frequent heavy drinkers, (2) low-functioning infrequent heavy drinkers, (3) high-functioning occasional heavy drinkers, and (4) high-functioning infrequent nonheavy drinkers. Relative to high-functioning infrequent nonheavy drinkers, individuals who were high-functioning occasional heavy drinkers did not differ on measures of functioning. High-functioning occasional heavy drinkers had significantly higher purpose in life when compared with poor-functioning profiles and greater satisfaction with life when compared with abstainers, which suggests that overall functioning and well-being do not require abstinence.
Mixed methods research with people seeking to resolve AUD supports the importance of incorporating indicators of recovery outside those related to consumption. For example, Kaskutas and colleagues15 surveyed 9341 individuals who self-identified as being in recovery to describe specific aspects of recovery from their perspective. Participants identified several aspects of recovery that were unrelated to the amount of alcohol consumed, including spirituality, dealing with challenging negative feelings, realistic self-appraisal, and an individual’s ability to look inward (eg, inner peace) and outward (eg, living a life that contributes to others and society) and to engage in self-care.
Further, Neale and colleagues16 developed a new patient-reported outcome measure of recovery from drug and alcohol dependence, named the Substance Use Recovery Evaluator, which was developed alongside addiction psychiatrists as well as staff and individuals in recovery (eg, former/current drug and alcohol service users). A 5-factor solution emerged: (1) substance use, (2) material resources, (3) outlook on life, (4) self-care, and (5) relationships. Similar to the findings of Kaskutas and colleagues,15 few items pertained specifically to substance use–related recovery outcomes. This research provides further support for the importance of nonabstinence-based factors, such as quality of life, social connection, and personal meaning, in recovery.
Nonabstinent Recovery and Social Determinants of Health
By expanding definitions of recovery to include nonabstinent recovery, researchers and clinicians can contribute to reductions in harmful use of alcohol and potentially improve whole-person health outcomes by acknowledging and addressing the multilevel, social ecologies that shape individuals’ lives.17 When recovery requires abstinence, it reinforces empirically unsubstantiated understandings of AUD that may enhance the stigma associated with AUD. Specifically, abstinence-only recovery can reinforce the notion that alcohol use is problematic only for those with AUD, and those with AUD will not ever be able to drink again.8 Requiring abstinence as the major focus of treatment can also lead to neglect of other areas that are important to health and well-being, including treatment for comorbid mental health disorders and building environments that support life functioning (eg, housing, access to medical care).17
The corresponding author previously conducted research at a community-funded residential treatment program that focused exclusively on abstinence. Unfortunately, many individuals who achieved abstinence were “successfully” discharged without housing in a major metropolitan city. Failure to address broader determinants of health precipitated a quick return to substance use, which would often result in individuals returning to treatment or prison shortly after discharge. Focusing on whole-person recovery and not just abstinence would have likely encouraged the same treatment program to consider the influence of housing status on individual well-being, quality of life, and health functioning. More importantly, it is likely the people served by such a program with a broadened focus would have far better chances of recovery.
Abstinence-based approaches to helping individuals who receive a diagnosis of AUD have been shaped by the disease-based understanding of AUD and the clinical setting, in which problem recognition and help seeking occur. Instead of focusing on negative self-definitions that arise from a disease-based understanding of AUD, incorporation of nonabstinence in recovery allows individuals to instead envision and actualize a life that would be of the greatest value to them. Expanding recovery to include nonabstinent understandings of recovery reduces stigma not only by deemphasizing a disease or pathology-based understanding of AUD, but also by shifting emphasis toward an approach that highlights individual strengths, improves intra- and interpersonal resilience, and engages social and community support systems.7
Importantly, when AUD is conceptualized as existing on a continuum of severity, rather than using a dichotomous disease-based model, more nontreatment-seeking heavy drinkers recognize their own alcohol use as problematic.18 As a result, defining both AUD and AUD recovery on a continuum could promote treatment seeking and motivate behavior change among a greater proportion of drinkers. From the perspective of improving public health and reducing population-level risky alcohol consumption, greater population health is achieved by promoting reductions in alcohol use among the whole population.9 As such, broader definitions of AUD recovery that incorporate nonabstinence as a pathway of recovery could enable improved alcohol use outcomes at the population level through reduced stigma, greater problem recognition, and increases in help seeking.
Recent work in the AUD field that relies on a framework of AUD focused on functioning and well-being as key determinants of recovery has theorized the importance of capturing the multilevel, socioecological context in which both drinking behavior and AUD recovery exist.19,20 Expansion of notions of recovery to include this constellation of influences on an individual’s life stands in stark contrast to most current clinical treatment models that focus on amelioration of disease and intraindividual mechanisms of change. Most treatment programs in the United States are primarily concerned with the initiation and maintenance of abstinence. A clinical treatment model that incorporates a broad understanding of recovery to focus on whole-person health might prioritize facilitating the building of social and community ties, promoting healthy diet and exercise, and identifying activities that do not involve using alcohol.
Research has also shown that financial stability as well as housing and food security are also particularly important in maintaining high levels of functioning and well-being in recovery.17 At the community level, Swan and colleagues19 found that individuals in communities with low rates of insurance and high rates of income inequality were least likely to achieve recovery, whereas those with high rates of insurance and low rates of income inequality were more likely to achieve a nonabstinent recovery. Limiting definitions of recovery to abstinence and the absence of AUD symptoms fails to capture the multidimensional and heterogeneous pathways to recovery that research has shown to exist among both treatment-seeking and population samples.5
Dr Boness is a research assistant professor at the University of New Mexico. Dr Kuhlemeier is a postdoctoral fellow at the University of New Mexico. Dr Witkiewitz is a Regents’ professor of psychology at the University of New Mexico.
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